Effective March 13, 2022
Updates to AIM Specialty Health® Clinical Appropriateness Guidelines
Effective for dates of service on and after March 13, 2022, the following updates will apply to the AIM Specialty Health® Clinical Appropriateness Guidelines for Advanced Imaging
Updates by section
Brain imaging
Acoustic neuroma
- Removed indication for CT brain and replaced with CT temporal bone
Meningioma
- Added new guideline for follow-up intervals
Pituitary adenoma
- Removed allowance for CT following nondiagnostic MRI in macroadenoma
Tumor, not otherwise specified
- Added indication for management; excluded surveillance for lipoma and epidermoid without suspicious features
Chest imaging
Pneumonia
- Removed indication for diagnosis of COVID-19 due to availability and accuracy of lab testing
Pulmonary nodule
- Revised criteria for follow-up of nodules detected on lung cancer screening CT based on Lung-RADS
Head and neck imaging
Parathyroid adenoma
- Added situations where surgery is recommended based on American Association of Endocrine Surgeons guidelines
Temporomandibular joint dysfunction
- Added duration of required conservative management
Abdominal and pelvic imaging
Azotemia
Hematuria
- Revised criteria for asymptomatic microhematuria based on American Urological Association guideline
Intussusception
Jaundice
- Added requirement for ultrasound prior to advanced imaging in pediatric patients
Sacroiliitis
- Added situations where advanced imaging is indicated (predisposing condition or equivocal radiographs)
Uterine leiomyomata (fibroids)
- Added requirement for ultrasound prior to MRI
- Expanded indication to include most other fertility-sparing procedures
Oncologic imaging
- Updated recommendations based on the National Comprehensive Cancer Network (NCCN) for the following:
- Breast cancer
- Hodgkin lymphoma
- Non-Hodgkin lymphoma
- Melanoma
- Neuroendocrine tumors
- Soft tissue sarcoma
- Testicular cancer
- Thyroid cancer
Breast cancer
- Updated clinical scenarios in chart for diagnostic breast MRI and PET/CT for management
Cancer screening
- Added indication for hepatocellular carcinoma screening
- Added age criteria for pancreatic cancer
Effective for dates of service on and after March 13, 2022, the following updates will apply to the AIM Specialty Health® Clinical Appropriateness Guidelines for Advanced Imaging of the Heart
Updates by section
Cardiac imaging
Coronary CT Angiography
- Removed indication for patients undergoing evaluation for transcatheter aortic valve implantation/replacement who are at moderate coronary artery disease risk
Effective for dates of service on and after March 13, 2022, the following updates will apply to the AIM Specialty Health® Clinical Appropriateness Guidelines for Radiation Oncology
- Removed Eastern Cooperative Oncology Group (ECOG) status as definition for performance status throughout guidelines
Effective February 4, 2022
Adjunctive Techniques for
Screening and Surveillance of Barrett Esophagus and Esophageal Dysplasia,
7.01.167
New policy
- Wide-area transepithelial sampling with three-dimensional computer-assisted analysis (WATS3D) is considered investigational for all indications, including but not limited to the screening and surveillance of Barrett esophagus and esophageal dysplasia
Drugs for Rare Diseases,
5.01.576
Site of service review added
- Adakveo® (crizanlizumab-tmca)
- Aldurazyme® (laronidase)
- Kanuma® (sebelipase alfa)
Hereditary Angioedema,
5.01.587
Site of service review added
IL-5 Inhibitors, 5.01.559
Site of service review added
Medical necessity criteria updated
- Nucala® (mepolizumab)
Indication: Treatment of adults with eosinophilic granulomatosis with polyangiitis (EGPA)
- Requirement added that patient has been taking prednisone or prednisolone
Indication: Treatment of adults and children age 12 years and older with hypereosinophilic syndrome (HES)
- Genetic testing is required to confirm that the patient does not have FIP1L1-PDGFRA kinase-positive HES
- Requirement has been added that the patient has been taking background HES therapy prior to treatment with this drug
Immune Globulin Therapy, 8.01.503
Site of service review added
- Asceniv™ (immune globulin intravenous, human - slra)
Intravitreal Corticosteroids,
5.01.619
New policyNew drugs added
- Iluvien® (fluocinolone acetonide intravitreal implant)
- Treatment of diabetic macular edema (DME) in patients age 18 years and older
- Ozurdex® (dexamethasone intravitreal implant)
- Treatment of macular edema following branch retinal vein occlusion (BRVO) or central retinal vein occlusion (CRVO) in patients age 18 years and older
- Treatment of non-infectious uveitis of the posterior segment of the eye in patients age 18 years and older
- Treatment of diabetic macular edema (DME) in patients age 18 years and older
- Retisert® (fluocinolone acetonide intravitreal implant)
- Treatment of chronic non-infectious uveitis affecting the posterior segment of the eye in patients age 12 years and older
- Yutiq® (fluocinolone acetonide intravitreal implant)
- Treatment of chronic non-infectious uveitis of the posterior segment of the eye in patients age 18 years and older
Pharmacologic Treatment of
Duchenne Muscular Dystrophy, 5.01.570
Site of service review added
Pharmacotherapy of Inflammatory
Bowel Disorder, 5.01.563
Site of service review added
- Stelara® (ustekinumab) IV
- Stelara® (ustekinumab) SC
Pharmacotherapy of
Miscellaneous Autoimmune Diseases, 5.01.564
Site of service review added
- Uplizna™ (inebilizumab-cdon)
Pharmacotherapy of
Arthropathies, 5.01.550
Site of service review added
Pneumatic
Compression Pumps for Treatment of Lymphedema and Venous Ulcers, 1.01.18
Policy
statement added
- The use of lymphedema pumps applied to the head and neck to treat lymphedema has been added to the list of investigational conditions
Site of Service: Infusion Drugs
and Biologic Agents, 11.01.523
New drugs added
- Adakveo® (crizanlizumab-tmca)
- Aldurazyme® (laronidase)
- Amondys 45™ (casimersen)
- Asceniv™ (immune globulin intravenous, human – slra)
- Cinqair® (reslizumab)
- Cinryze® (C1 esterase inhibitor [human])
- Kanuma® (sebelipase alfa)
- Stelara® (ustekinumab) IV
- Stelara® (ustekinumab) SC
- Uplizna® (inebilizumab-cdon)
Total Artificial
Hearts and Implantable Ventricular Assist Devices, 7.03.11
Medical
necessity criteria updated
- For implantable ventricular assist devices (VADs) for end-stage heart failure, criteria updated based on the 2020 MOMENTUM 3 clinical trial
- Criterion added of cardiac index while patient is not on inotropes
- Heart transplant ineligibility criteria removed
Xolair® (omalizumab), 5.01.513
Medical necessity criteria updated
- Indication: Treatment of moderate to severe asthma in adults and children age 6 years and older
- Requirement added that an adult patient is not a smoker, or is enrolled in a smoking cessation program
- Requirement added that the patient weighs between 44 and 330 pounds
- Indication: Treatment of severe chronic idiopathic urticaria in adults and adolescents age 12 years and older
- The requirement of failure to respond to two therapeutic regimens has been reduced to one
- Indication: Treatment of adult patients with inadequately controlled nasal polys
- Requirement added for a pre-treatment IgE antibody score greater than or equal to 30 IU/mL
- Requirement added that the patient weighs between 66 and 330 pounds
Effective January 7, 2022
Cervical Spine
Surgeries: Discectomy, Laminectomy, and Fusion in Adults, 7.01.560
Medical necessity criteria updated
- Site of service (off campus-outpatient hospital/medical center, on campus-outpatient hospital/medical center, and ambulatory surgical center) has been added to the policy for medical necessity review for single-level cervical decompressions and single
level cervical fusions (CPT codes 22551, 22554, 22600, 63020, and 63045)
Hysterectomy for Non-Malignant
Conditions, 7.01.548
New policy
- Hysterectomy, with or without salpingo-oophorectomy (removal of fallopian tubes and ovaries) is considered medically necessary when criteria are met
- Conditions included in the criteria: abnormal uterine bleeding or uterine fibroids (leiomyomata), adenomyosis, endometriosis, genetic predisposition to cancer, symptomatic pelvic organ prolapse
- Conditions excluded from review are hysterectomy for malignancies or conditions highly suspicious for malignancy (eg, ovarian mass) and hysterectomy for gender-transition/affirming surgeries
- Site of service review is included for laparoscopic-assisted vaginal hysterectomy and vaginal hysterectomy
Lumbar Spinal Fusion,
7.01.542
Medical necessity criteria updated
- Site of service (off campus-outpatient hospital/medical center, on campus-outpatient hospital/medical center, and ambulatory surgical center) has been added to the policy for medical necessity review for single-level lumbar fusions (CPT codes 22553, 22558, 22612, 22630, and 22633)
Site of Service: Select
Surgical Procedures, 11.01.524
- Single-level cervical discectomy and lumbar spinal fusions, along with some hysterectomy procedures, have been added to this policy as now requiring site of service review for medical necessity and are indicated by the following codes: 22533, 22551,
22554, 22558, 22600, 22612, 22630, 22633, 58260, 58262, 58263, 58267, 58270, 58275, 58280, 58290, 58291, 58292, 58294, 58550,58552, 58553, 58554,63020 and 63045. HCPCS code C1726 was removed.
Effective December 2, 2021
Pharmacotherapy of Miscellaneous Autoimmune Diseases, 5.01.564
New drug added to policy
- Arcalyst® (rilonacept)
- Treatment of cryopyrin-associated period syndromes (CAPS) in adults and children age 12 years and older
- Treatment of deficiency of interleukin-1 receptor antagonist (DIRA) in adults and children weighing at least 10 kg
- Treatment of recurrent pericarditis (RP) in patients age 12 years and older
Effective November 5, 2021
New policy
- Injecting a tissue graft from a donor into the space between the spinal vertebrae as a treatment of degenerative joint disease is considered investigational
Medical
Necessity Criteria for Pharmacy Edits, 5.01.605
Testosterone Replacement Products
New drug added
- Aveed® (testosterone undecanoate)
Miscellaneous Oncology Drugs,
5.01.540
New drugs added
- Abraxane® (paclitaxel protein-bound particles)
- Treatment of metastatic breast cancer
- Treatment of locally advanced or metastatic non-small cell lung cancer (NSCLC)
- Treatment of metastatic adenocarcinoma of the pancreas
- Arranon® (nelarabine)
- Treatment of T-cell acute lymphoblastic lymphoma (T-ALL)
- Treatment of T-cell lymphoblastic lymphoma (T-LBL)
- Empliciti® (elotuzumab)
- Treatment of multiple myeloma
- Erwinaze® (asparaginase erwinia chrysanthemi)
- As a part of a multi-agent chemotherapy regimen for the treatment of acute lymphoblastic leukemia (ALL)
- Halaven® (eribulin mesylate)
- Treatment of metastatic breast cancer
- Treatment of inoperable or metastatic liposarcoma
- Yondelis® (trabectedin)
- Treatment of inoperable or metastatic liposarcoma or leiomyosarcoma
Non-covered
Experimental/Investigational Services, 10.01.533
New policy
- The safety and/or effectiveness of treatments, procedures, equipment, drugs, drug usage, medical devices, or supplies that have not been supported by a review of published medical and scientific literature are considered experimental/investigational
- This policy lists several services that are considered experimental/investigational